Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach

Abstract

Background: Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes.

Methods: A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia.

Results: The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27).

Conclusions: Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.

Keywords: Abdominal surgery; Network meta-analysis; Prehabilitation.

Fig. 1

Cumulative proportion of compliance rate

Fig. 2

Overall morbidity rate: Network geometry (A), Heat plot (B), Funnel plot (C), Forest plot (D), and Density plot (E). AE aerobic exercise; RT resistance training; IMT inspiratory muscle training; NST no specific training; OR odds ratio; p-score: the intervention is considered among the best if p-score was ≥0.66; when p-score was 0.65–0.33, the combination was judged inferior to the best/better than the worst; when p-score was <0.33, the combination was considered among the worst

Fig. 3

Length of stay: Network geometry (A), Heat plot (B), Funnel plot (C), Forest plot (D), and Density plot (E). AE aerobic exercise; RT resistance training; IMT inspiratory muscle training; NST no specific training; MD mean difference; p-score: the intervention is considered among the best if p-score was ≥0.66; when p-score was 0.65–0.33, the combination was judged inferior to the best/better than the worst; when p-score was <0.33, the combination was considered among the worst

Fig. 4

Pneumoniae rate: Network geometry (A), Heat plot (B), Funnel plot (C), and Forest plot (D). AE aerobic exercise; RT resistance training; IMT inspiratory muscle training; NST no specific training; OR odds ratio; p-score: the intervention is considered among the best if p-score was ≥0.66; when p-score was 0.65–0.33, the combination was judged inferior to the best/better than the worst; when p-score < 0.33, the combination was considered among the worst